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The Top 5 Osteoporosis Lies

Words can – and do – make a big difference. Perhaps the use of the word “lies” in today’s blog post title may sound a bit harsh to you. In fact, at first I wrote “myths” instead, but I soon realized that it didn’t apply.

As defined by the online dictionary, a myth is “an unfounded or false notion.” A lie is “something meant to deceive or give a wrong impression.” Notice the subtle difference between the two. Myths are not created with a specific purpose; they simply spring up and innocently continue into the future. And myths typically develop over a long period of time, passed on from generation to generation. On the other hand, lies have a purpose, they are invented to fulfill an agenda. As the definition states, lies are “meant to deceive.”

Once you’ll read what’s coming up next, I’m pretty sure you’ll agree with me: it is perfectly warranted to use the word “lies” instead of “myths”.

Let’s take a look now at the top five osteoporosis lies.

Big Lie #1: Osteoporosis is a devastating disease.

In Chapter 1 of the Save Our Bones Program I shatter the current osteoporosis definition and explain why it is not a disease. In essence, the medical establishment wants you to believe that you are disease-ridden and your bones have deteriorated to the point of no return… unless you take the miraculous osteoporosis drugs. If you haven’t yet, check out the blog post ‘Osteoporosis is NOT a Disease’, where I summarize the topic, and download my free Natural Bone-Building Handbook.

Quite eye-opening, to say the least…

Big Lie #2: The most popular Osteoporosis drugs significantly reduce the risk of fractures.

Leaving all the terrible side effects aside, bisphosphonates – and other drugs as well – have shown a very poor (if not practically insignificant) fracture risk reduction. That is, if you know how to read between the lines.

Here’s the scoop. Studies typically reveal both relative risk of fracture reduction and absolute risk of fracture reduction. I’ll give you an example using hypothetical numbers. If someone has a 10% risk of getting an osteoporosis fracture during the next 5 years, and if that risk is shown to decrease from 10% to 8% by taking the drug, the relative risk reduction will be 20% calculated as follows: (10% – 8%) / 10% = 20%. However, the absolute fracture risk reduction is a mere 2% (10% – 8% = 2%).

Now a real example: a meta-analysis study on alendronate (the generic name for Fosamax) reviewed fracture risk of 12,068 women taking the 10 mg dose of the drug. Among the results it shows a 23% relative risk reduction but only a 2% absolute risk reduction for non-vertebral fractures.1

And here’s another “magic number” you’ll seldom hear about: the nefarious “number needed to treat” (NNT). To figure out the NNT result, you simply take 1 and divide it by the absolute risk reduction percentage. So using the same alendronate study result as an example, 50 women (1 divided by 2% or 0.02) would have to take the drug so that just one could benefit from the fracture risk reduction! What about the other 49 individuals? Hardly a benefit, I’d say, especially if we consider the large number of adverse effects related to the drug.

So much for statistics, huh?

Big Lie #3: When it comes to treating osteoporosis, you should always listen to your doctor.

Doctors are taught in medical school that “to cure” is “to prescribe”. I can’t help but think of what Einstein said: “The only thing that interferes with my learning is my education.” Fortunately, a select minority breaks away from the herd.

Plus doctors are so busy with their practice, that they don’t keep up with the latest research. And this is not hearsay. A study published in the prestigious New England Journal of Medicine and written by a doctor, states that an alarming number of doctors rely on what they learned 20 years before and are in the dark about new – and even not so new – research.2

The Wall Street Journal also picked up on this hot-button topic. In an article titled “Too Many Patients Never Reap the Benefits of Great Research”, the author – another doctor – bluntly states that doctors ignore new research and refuse to acknowledge that they need to keep up with new scientific data.3

Scary, right?

Big Lie #4: Diet has no effect on osteoporosis.

Mainstream medicine insists that bones can’t renew themselves after you’ve reached a certain age. But nothing is further from the truth. Bones are active tissue, that react astonishingly well if you give them what they need.

And guess what; your bones don’t need chemicals and drugs. They require nutrients for nourishment, remodeling and renewal. The best way to get bone-healthy nutrients is from foods and supplements, especially the Foundation Foods and Foundation Supplements.

But foods can do even more for your bones. Because when you follow the acid/alkaline balance as I explain in the Save Our Bones Program, your bones will retain the minerals they need to thrive and rejuvenate.

In fact, check out the amazingreal life results our community members have experienced thanks to the changes they’ve made to their diets.

Big Lie #5: Osteoporosis is the main cause of fractures.

Not so. Fractures occur in people of all ages, and most often without Osteoporosis. For example, an article in the Journal of Clinical Endocrinology & Metabolism titled “Hip Fracture in Women without osteoporosis” by Stacy A. Wainwright, followed the fracture incidence of 8,065 participants with a median age of 72. The author concludes that “with the exception of the oldest women, after five years of follow-up, the majority of hip fracture cases were without hip osteoporosis, regardless of age.”

Please feel free to share this information with family, friends, and co-workers.

My Doctor has recommended Fosteum Plus. You have said you don’t recommend it, as one of it’s ingredients is genistien, which is soy based therefore, a phytoestrogen. The ingredient is listed as ” genistein aglycone” isolated from a natural “non soy” source. Is this still a potential problem? I have used AlgaeCal in the past, with no significant results, and am following a strict diet as well (mostly veges, light on the meats, no sugar, no starchy carbs) I also have much pain in my neck and spine from degenerative disks. Thanks for any suggestions, and for responding to my question about Fosteum Plus. (I have your book, thank you for the useful information.)

I wanted to thank the person who told me about this web site (Marilyn H.) this site is great. Also wanted to thank Sue C. for telling me about the weight vest by NYKNYC
I got mine around the Holidays and have been using it every day . What a great easy way to get your weight bearing workout. Sure beats spending hours in my gym lifting barbells I put it on and go for a walk so I dont miss the beautiful Spring weather ! I am no longer a prisoner of the gym!! Hooray.
can I put up the web site for anyone who needs a vest?http://www.nyknyc.com

The Save our Bones book is really helpful and educational. I have stopped taking bisphosphonates now – and will rely on diet and exercise. I underwent major dental surgery recently and hope that the bisphosphonates I took in the past dont give me jaw death!! I am amazed that doctors are not aware of the truth. What are your views on calcium supplements – are they another risky tablet to take

Vivian, could you please tell me if panadol osteo is a dangerous drug as I have been taking since fall, fractures and back pain. I am on good diet and have been using alkaline water for years but ph is still acid. I am on heart medication, minax, norvasc, iscover and oroxine after heart attack and stent put in artery.

ivian, could you please tell me if panadolosteo is a dangerous drug. Since fall 2 years ago with back pain it has been prescribed for me, not sure if it helps. I am on good diet but ph is acid although using alkaline water for years but on heart medication after heart attack and stent i artery.

Hi Vivian, I pray you are doing well. I have your Save Our Bones Program but I need your advise on an calcium herbal extract which contains Horsetail, Indian Tobacco, Dulse, Red Raspberry leaf, Oat Straw, and Knitbone. I have no idea if this is a good calcium product, please advise if you can. Thanks

Hello. I was just recently diagnosed with Osteoporosis, in my left hip, and spine. I was prescribed Fosamax. I went on-line, and read the law suit pending against Merk, the attorney called me back, and shared the dangers of broken femurs, etc. The side effects look worse than the Osteo. I have been working on a ph balanced diet for a number of months, take Ibprophen at night to sleep, but have not seen any change in bone density yet. I went off of soda pop, and tomatoes. Have been off red meat for years. Not sure yet about right exercises. I appreciate everyone’s comments, and advise, and will try them. God Speed to all for good recovery.

Thank you for your much needed information. I am an 80 year old female that has been in 5 car accidents that involved my lower back vertebrae. I take Wild Salmon Oil, 1000 mg.and Glucosamine Hydrochloride,500 mg., I eat mostly Vegetarian and watch my PH balance plus do 3 specific exercises on my bed twice a day. This routine has brought me out of pain that used to put me in the Hospital(once with such severe pain that I could not sit up in bed). The Ambulance drivers had to roll me onto a stretcher to take me to the Hospital. I agree with you wholeheartedly on the “lie” aspect that the Pharmaceudical Companies try to sell us. Keep up the good work Vivian!

Yes, I used Evista for over a year after HRT. I quit because of leg cramps, and now it is not recommended for me because of CAD, and the possibility of a stroke. I feel it is much safer than most of the osteo drugs if you don’t have heart problems. My bones were actually fine while on HRT, but after CBAG surgery I can no longer take estrogen. Therefore, I have used the natural approach for the past two years. This is the ideal, but I would also go on Evista if I could. My former doctor said he would never prescribe Fosamax, and his choice of safety was Evista if I didn’t take estrogen. You probably should ask Vivian, as this is a personal experience, and I have no medical training.

Vivian,two weeks ago I had a tumble on a sidewalk and had severe injury with subsequent massive bruising to my left temple area, eye, face – also left hip area. ER the next day with numerous x-rays, CT scan of head, showed NO fractures; only a sprain of the right wrist! I had ordered your book probably two years ago and had been following most of your suggestions on diet and the refusal of the suggested drugs for osteopenia. BTW – I’m 83 years old and on Coumadin.
I seldom eat red meat, use only almond milk, eat mainly fruits and vegs. as per your acid/alkalin guidelines. I’m now convinced that NOT taking the drugs saved me from broken bones. Everyone is amazed that I didn’t have a broken bone.

Just wanted you to know that your plan seems to have worked well in my case. Incidentally, I had to cancel an appt. for a bone density test. I told them I had already taken the test! Just wish mine hadn’t been so painful.

My e-mail address is above if you want to contact me. Keep up the good work.

I’m so glad you didn’t break a bone, Marie! I thank you for sharing with us the good outcome of what could have been a terrible incident. I wish you a quick recovery from the bruises and wrist sprain. Keep up with the Program and stay healthy and active. My warmest regards, Vivian.

Each day I fix a meal from your diet. I feel so good and it tastes good too. My daughter is a vegan and she has wonderful recipes so we share. I’m also exercising more and I’ve joined a hiking club. Thanks Vivian for so much encouragement. My bone scan was a -4 last year so I’m trying hard. Nancy

I value all your informations, research, and recommendations. Recently, I
met many hearlth problems, I like the natural way, but some are in degeneration, what can I do? or might be I didn’t do it perfect.
Thank you

I just returned from the doctor and was told that I now have osteoporosis. It only dropped from -2.4 to -2.5, since I have been carefully following the Save Our Bones program for 2 years. I was told that I now have the disease and that I needed to be on meds. 2 years ago I took one Actenol (1 month) and was very sick for 3 weeks. I was given Atelvia 35 mg. for 1 a week. I’ve read the side effects and they are not good. I was bascially told that I would be immobile if I didn’t take the meds. I am not sure what to do. I just read some of the other postings about EZ orb calcium. It seems like you feel it is okay to take. Has this increased bone density in anyone?

I enjoy everything you post Vivian. And I have a question that puzzles me. I am eating and drinking better than ever before plus I take supplements. For about 5 months now my forehead and side of my face have broken out in blemish and they don’t go away. What can that be? Am I allergic to something all of a sudden? I am 59 years old.

Hi to woman with new blemishes on face and forehead. Before you get diagosed by a dermotologist with rosecea and being prescribed antibiotics saying there is no cure for it…..

check out ‘demodex mites’ what they are, then how to get rid of them. Apparently most facial problems with what they say is acne are invisible mites that were once symbiotic turned parasitic and cause breakouts.
I am not in the industry but have the mites and am treating with oils that go deep to kill them and it can take 120 days as they cannot be killed unitl they surface…..
you can read on wikipedia, good luck!

Vivian. Thank you so much for this report. I have been very depressed since I found out about the Osteoporosis in my spine and especially left hip. I am afraid all the time. If I understand your report, it seems that as many people without O have hip fractures as those with it. I try to watch my step but want to be able to get out and walk. I am losing a lot of muscle.

Exactly, Lynn. Anyone can fracture a bone upon impact — that does not necessarily indicate any underlying issue with the bones. Check with your doctor of course, but movement is important and will help to strengthen your bones as well as your muscles.

Hi Becky – Ezorb calcium (aspartate anhydrous), is a combination of a calcium atom and l-aspartic molecules bound by chelation, and chelated calcium products are an acceptable alternative to organic calcium.

Vivian, Thank you for responding to my question on EZorb. So, do you think this is a good product to help towards my osteoporosis? I have to see my doctor next month and I will tell her I am taking these. I only been taking them for 1 month now. Thank you.

Vivan – THANK YOU for your clear, concise interpretation of the research around osteoporisis. Most of all, thank you for accepting all of us as intelligent, reasoning beings, perfectly capable of managing our own health. I feel very fortunate having a family doctor who respects my ability to do just that. She sees that I am a healthy and active 77 year old. If I need her intervention, I just ask. Actually we are partners in my health.

I follow all your Save Our Bones information plus take a liquid Silicon called Biosil. It is supposed to help metabolize the calcium and fill in any holes in the bone. I do feel that my balance is better and feel stronger. Could you comment on this. Thank you

I also take Biosil for my osteoarthritis as well as my bones and I do feel stronger in those areas. I knew it was good for bones, hair, skin and nails too. I did not know exactly how Biosil worked in the bones till I read read your comment. I wouldn’t be without my Biosil!

I agree of what you said,don’t worry I believe you anyway.I am also diagnose before with osteoporosis,but I just ry to look after my foods.I don’t drink Alcohol, I stop eating fatty foods due to my Cholesterol,I was also told by myDoctor I have fatty liver,high enzymes of 49 the reading.Also I have high Blood Pressure. I have very many problem. I am not taking medicines or drugs, because when I read all the drugs that are prescribed it has many side effects.I can get more problems at the end.

So I do not know whether I am doing the right thing to myself.My friend said, I must not stop the blood pressure tablets and the simbastatin I might have stroke.These drugs are all dangerous due to the side effects. So I just wait when will this stroke comes to me.

One year already I have no stroke,maybe my diet have work. I also imparted my idea to my best friend because she has severe head ache wake up at 2am and4am it will not stop if she will not take paracetemol or Migralive.She came to me for 9 days she ate what I have eaten,she has only 3 attacks of head aches.So she said I will continue the die that you have taught.

The wife of my friend take 12different kinds of Medicines at the end she died quickly.My other friend taking 18kinds I look at her she looks bloated.the other one takes 40 tabs I said how will you remember all this,the time and so on

I am very scared of all the drugs.Well it is up to the individuals. I was givenadcal D3 when I read it will cause heart attack, I stop so my nails was broken again and flaking became very short again.

Well, I can’t do anything.I have rheumatoidarthritis.The joint of mythumbs are swollen,I just ignore it.

This is important. Stop drinking all liquids that have water from the tap…..flouride from our tap water (coffee, tea, cooking, all juices from store) are made with tap water that has flouride and 300 more contaminants unregulated by citey state or nation.

Literallyk over night I could feel my hips, bones and joints get stronger, all inflammantion in fingers gone, and I feel like I’m 20 years younger.

I do not take any medications at all. Try to change your water and see what happnes.

Hi, I have had porosis for about 17 years. I have had the norm rib fractures and compressed fractures of the spine but now have 3 crumbled vertebrae and in plenty of pain. I have so many spasms which are obviously exposing nerves and causing horrendous pain and not being able to get into my bed as my legs are painful to lift and even if I could get into bed, I can’t turn over. I have always avoided drugs and have been taking a complementary French remedy but I did take Fosamax for a couple of years as it began to get worse as shown on the Dexa.
I am now being told if I don’t take drugs, I will have no quality of life and I really do not want to go here again with all this pain – help !!
I know nothing will replace the density (well, I don’t think so?) but what can I do to avoid this happening to me again?

Hi Jean – I’m sorry to hear about your fractures and pain. To enhance fracture healing, it’s important to make sure that sufficient bone and collagen building minerals are available, such as calcium, magnesium, zinc, boron, manganese, and copper. Vitamin K and D3 are also very important, as well as B12 (preferably taken with the rest of the B complex) and Vitamin C. Also, some antioxidants (lycopene and polyphenols) help build new bone. Maintaining an alkaline body pH is also very important, so you might want to look into The Save Our Bones Program. All these recommendations are also applicable to the prevention and reversal of bone loss.

A little Late Vivian but thank you so much for replying and the advice. as soon as I feel I can cope with the concentration of what I have to do, I will. I really don’t know what we would do without your on-going help and advice. Many thanks.
Jean

Hi Susan – As I explain in this article, and in the Save Our Bones Program, these numbers really don’t mean a lot in terms of absolute or individual risk. Bone health is about much more than bone density. But although I do not buy into this system of “diagnosing” osteoporosis, here are the diagnostic parameters for osteoporosis established by the World Health Organization (WHO):

A T-score between +1 and -1 is normal bone density. Examples are 0.8, 0.2 and -0.5.
A T-score between -1 and -2.5 indicates low bone density or osteopenia. Examples are T-scores of -1.2, -1.6 and -2.1.
A T-score of -2.5 or lower is a diagnosis of osteoporosis. Examples are T-scores of -2.8, -3.3 and -3.9.

Thank you, Vivian, for everything you are doing. You have been working tirelessly to get the word out. I am so glad that I found you, and that you were available to me when I needed it. I am worried about proposed legislation in Congress that is aimed at controlling the internet in so many ways. One minor thing they want to do is “protect” us from “dangerous” health information that is currently freely disseminated online. We need to be vigilant and proactive so that we don’t lose this wonderful tool for getting out the truth about so many things. Without you and many like you who give us real and natural alternatives to pharmaceuticals, we would be at the mercy of mainstream medicine who in turn is hostage to the big drug companies. Big Pharma lobbyists have great control over our legislative branch, too. And it’s all about money. They are circling their wagons and taking the first steps toward shutting you down. So beware.

By the way, not enough is said about “defensive medicine.” All doctors practice medicine in a manner so as to avoid lawsuits. Period. The generally accepted Standard of Practice in treating osteoporosis is to prescribe a bisphosphonate. To not do so would be malpractice. As many of your readers have testified, most doctors get extremely testy if you challenge them on this. I have had the same sad and unfortunate experience. But in a free and open society such as ours, those of us who want an alternative should have access to it. Freedom of information goes in all directions. End of dissertation.

Vivienne,having taken bisphosphonates Fosimax,& Alendronate for 10 years. Having broken my wrist,& cracked my pelvis in the last 4 yearsI asked my G.P.if he would advise stopping Alendronate.He more or less shrugged his shoulders & said it was my decision.I have been off them for only four months, but think I feel generally better.I intend to see how things are after 1year.Would the risk attached to these drugs be lessened by 1year free of them. I am 77.
Thank you Brenda Russell

Hi Brenda — When you stop taking the osteoporosis drugs, the free flowing drug gets eliminated via the urine in a few months (drink plenty of fluids to accelerate this process) and as bone remodeling starts again, new bone will cover the old bone to which the drug attached itself and will render the drug inactive. If you’d like to speed the removal of the drugs from your system, take a look at my Rapid Cleanse: The 7 Day Osteoporosis Drug Cleanse.

You do have hope, Brenda.
I had taken Fosamax for 7 years and in all those years, I was in the osteopenia range bordering into osteoporosis. I had been made to feel the news was dire and so I willingly took the drug till in the fall of 2010, when a friend of mine whose daughter worked for a pharmacist said her daughter’s boss said Fosamax was bad for you and and that shouldn’t be taking it. A few months later when I had time, I found myself reading and learning on the internet late into the night and was horrified to discover that so many of the recent symptoms I had been having could have been attributed to Fosamax. I came upon the Save Our Bones website and as well as others, and I never took another pill. I ordered Vivian’s book and have tried to eat more fruits and veggies and also took Algaecal as I’d found it at my Bay Pharmacy until she wasn’t able to get it anymore.I see more ‘organic’ bone supplements are becoming available.

I am 69 and I’d like to report my T scores, before and after going off the drug.

November 2009…
left femoral neck was -2.1
L3 lumbar vertebrae was -2.2
(L1, L2 & L4 were discarded because of degenerative state)
Both of these scores said no evidence of osteoporosis.

After stopping Fosamax in 2010 my bone density results in December 2011…
left femoral neck was -2.4 with 0.6% deterioration
L3 lumbar vertebrae was -2.0 with 2.7% IMPROVEMENT.
The final comment was…
“Although the obtained measurements place the patient in the osteopenic range with a moderate risk of fracture; however, given the stability in the left neck of femur and the improvement in the lumbar spine and if the patient is currently on treatment, this will decrease the risk of fracture.”
Little did the radiologist know that I had been off of Fosamax for just over a year at that time!!

I would say since coming off the drug, I might have expected some decline in the first year, that I came out pretty well with slight decline in my femur and improvement in my spine!
I attribute this to my new awareness of what is needed to keep my bones healthy and taking a plant based bone supplement, possibly even more because though I try with the diet, I know I can do better.
So, good luck to everyone out there! And thank you, Vivian.

Thank you Vivian for keeping us informed. If it weren’t for you we would be at the mercy of doctors misinformation and big “Pharma”. Please continue to keep us educated on such an important subject.
Gerri D.

I have greatly benefitted from your research and enjoy your news items. Please answer this question for me. Somewhere I have read that eating fresh spinach acts against calcium consumption, drawing the mineral from bones. This is not stated in your work. What is your feeling about spinach?

Hi Marce – Spinach (as well as several other foods) do contain oxalates, bu while laboratory studies have shown that oxalates may interfere with calcium absorption, the reduction is relatively small. For slightly better absorption, you could take your calcium supplements a couple of hours before or after a meal that contains foods with oxalates.

Hello,,,I been going to the GYN EVERYYEAR. My doctor said I have a little
Osteo on one hip and a little Osteo near my tale bone….and of course
wanted me to take the Drugs, you know what they are. I said NO.
I take a Supplement. Three time a day. Citracal Calciium+D3 Bone Density
Builder..I have a good diet and I do excersise, Moderate Weight lifting,
bike, walking. Alwayw take stairs whereever I go..
I do believe in what you say. I will order your book.

Hello, I was wondering if you have any findings on being gluten-intolerant, and if it has any effects on your bones. I know that being gluten-intolerant causes a malabsorption problem if not diagnosed. I am 54 yrs. old and was diagnosed with osteoporosis around 2007. At that time the range was borderline from osteopenia to osteporosis. Now they say I have osteoporosis with a reading of -2. something. I was taking fosamax for one year, experienced alot of muscle pain. Doctor prescribed Actenol, didn’t suffer from muscle pain, but couldn’t afford the drugs, and was leary of the side effects. They resently recommended I do the reclast method, but they were suppose to call me to set up the appointment, which I haven’t heard back from them. I wasn’t crazy about the idea either. I have recently been researching on gluten-intolerance after being diagnosed with acid reflux, diverticulosis, gastritis, and osteoporosis after a colonoscopy at age 54. But I have read that being gluten-intolerant or if you have celiac (which according to the dr. I do not have), it could be related to getting osteoporosis. There is no family history of osteoporosis. I’m wondering if I’ve had a gluten-intolerance for a long time and possibly developed osteoporosis or it contributed to osteoporosis. If you have any research on this matter, I would greatly appreciate this. I do intend to get your book, it seems to be packed full of information on osteoporosis. I don’t want to have to take expensive drugs but rather do it the natural way thru foods and vitamins. Thank you for your response.

Indeed gluten intolerance even if without big symptoms will cause poor absorption of minerals. There are tons on information on this on mercola.com. ( I have no financial interests there) I would suggest the best multiminerals (mercola) along with vitamin K2 and if you can afford it Ezorb. Ezorb calcium is delivered directly into the cells and does not need vitamin D nor magnesium to be absorbed. It will be absorbed even with a gluten intolerance. Mercola’s multivitamins contain lots of easily absorbable magnesium and other minerals. If you are on blood thinning medication ,you can use vitamin K2, but only up to 45 micro grams per day, but not without consulting your health care professionnal.
Best of wishes. (luc@bondocteur.com)

Vivian, thank you,once again for some good advice… I shared your message on my FB page….I am dreading going to the doctor in March because I know he wants to try me on another osteo drug, which I am going to refuse…I think it is Prolia, that he thinks I need… I am taking good vitamins, calcuim and doing exercises as my knees allow… I am concentrating on exercising my back and doing those awesome wall push up you mentioned….I do range of motion exercise for osteo, so that I do not flair up the arthritis in my knees…

Thank you for all the good information you send to us… I appreciate it.. I am working hard right now, so that my bone density test in April goes well…

Lie #4 is one of the most easily disproved – if bones can’t renew themselves after a certain age, how come fractures heal? I shattered my wrist bone into five pieces just over 3 years ago at the age of 63. It’s all healed up now and as strong as the other wrist.

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This information is not intended to replace recommendations or advice from physicians or other healthcare providers. Rather, it is intended to help you make informed decisions about your health and to cooperate with your healthcare provider in a joint quest for optimal wellness. If you suspect you have a medical problem, we urge you to seek medical attention from a competent healthcare provider.